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• [SEC a NE[ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT .c IJ("i — 1 2005 304 E WESER AVE,3"°FLOOR ENVIRONI !EN i HEALTH STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT PERMIT/SERVICES THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: __ TANK RETROFIT _PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENY REPAIRIRETROFIT '------------- ---------------------.--------------------------- -• I EPA SITE I) I PRO`=CORCACC E;TELEPI'MIM p �7 J IFI FA�LITY NA?4i --------------------------_= —.C1l-------- ------------------ Y' :=-Y!„-- a�-^7�cQ�------ ----------- ------------ - -------�L/o1nm -------------- ------------------------------ L ----------- -----------L i OCSs STAH6�'•---l�eS ...L-t>a ._ ^ -------------------------------------------- T ------------•^ -------- •• -- - --...i ITI OFdIER/OPBLLTOR --------------------------'---------... I DSIOT� q - 1 C -------- ---- - ^ -----------------------• ---------------• -----------------I------ ---^--------------- ----------i PWAZ I I ------------------- -?(1_Y, 9� ------ - ---- -• ----------.._--------------• --zU R , ,ms s z1 � ' ---------��- -,y��ol =-- --------------- ---------------- T �Y---- ---�-/-- -------------r-- - ---- - --- R I nzmt De / �- Cp -W ------------------ A 2 I II -- --- - ---------------------------------------- --- - I C I OTHER IMMENATI01 IT---------------- ----------_-.,---------------------------------...+--------------------------__------------I 0 1 I PF4WE ; --------------------------I I I ( PHONE 0 I +---Illlllllllllllllllllllllllllllll----••----------- -” " _ _"""'"-__"'_""" " -----------------------•-------------••----I '--_---" I I TAM ID 4 I TAM SISL' I CRDMICns smRw CSIRRFNILY/vRzvImstY DATE DST INISTALLEO I I I 19--1 I T 139- I I I I I A119- I IN139- I I I IK139- 39- I 139• I � I I ---1111 III IIII III IIIIIIIIIIIIII lllllllllllltllllllll IIIIIII IIIIIIIIIIII IIIIIIIIIII{IIIIIIIIIIIII11111111111111111111111111111111 IPI 1 1 L 1 APPROVED APPROVED WITFT CO2IDITIOII(S)� DISAPPROVED A I (SEB ATTAC 3 K I ?Lax RUVXS F.RS NADA PAT. b .___{IIIIIIIIIIII{IIIIIIIIIIIIIlIIIIIIIIIIIII►Illllllllllllllll -HTI)ll III a lllllllllllllll IIII Illlllllllllllll I I A2?LICA.`rC MU4T P.RFORM ALL WORK 11Q ACCORDANCE 1VITH 6AN JOAQOT21 CODxIY ORDSNAX>z=. e'IATE LABS, AND RDLPS AMID RSQII+tiT16NS OC 1 SnN Jelt OAOO= COONfY, MMjRO =?r)%L)ISAI.TH DZPAMMrr. OWER OR LICMED A='S SIGNATURE CERTIFIss THE FC1L��! "I CERTIFY I I TFIAT IN THE P=-UDf MC6 OP TIM WORK FOR VMCH TTaR PERMIT IS I69OED. I SHALL NOT EaLOY ANY PMWN IN 6=1 A M MMR As MO I ABC--,% SUBJECT TO 140 im-S COMPERBATION LAWS OF CALIFORFIIA." CONI'AACPOR'S =nxi OR SUBCONrIPACT32M SIMATVR. CERTIFIES TNR= I P0t1zWIPO: •I CERTIFY THAT IDN MR PCRBORDu=OF THC WORK FOR WRICH THIS PMMIT IS ISSUP.D, I ..ALL EMPLOY P1ItS011S SUBJECT'TO I I WOR1]O RR 6 C'a+T2"LATIOT7 TAWS OF CALIFORNIA." I I I � 1 1Tlrce _1 DATE I I ADv[.ICAxT's SZGiATUF-&; / I + ---- - -- -• ---- ---------• ---- ...,---------------- --------------'--------------------------------------------- >.v-Ga-O CC�o� Uv— e.QQ4-C�Jt�cl, BILLING INFORMATION: �. `e`"P"� � -`O �`"� "� N'0 Q—, aV Qc>-wQ--To - s-� Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name Address Phone i